PLEASE PRINT LEGIBLY USING BLUE OR BLACK INK
Youth Voucher Program Questionnaire
***THIS IS NOT AN APPLICATION OR A VOUCHER FOR SERVCES.
Please return this form to your child’s school nurse who will complete the application process***
Applicant (Child) Name:
County of Residence:
Applicant Address: __
School Attending: ______________________________________________________
Zip Code: _______________
What type of assistance does the child need? (check only one box)
Eye Glasses only OR
Is the child currently enrolled in school and between the ages of 2 and 19 years?
Eye Exam and Glasses
Is the child or child’s parent/legal guardian a US citizen or documented immigrant with a Social Security number?
Check NO if the child or parent/legal guardian has a Taxpayer ID number (begins with the number “9”) or if the number contains letters.
How many people (children and adults) are living in the household? ___________
What is the total YEARLY household income before taxes? ____________
Household income includes employment, severance, unemployment, child support, social security, SSI, disability, retirement, AFDC, workers
compensation, and food stamps.
Does the child have vision benefits under TRICARE?
Does the child have vision benefits under NC Medicaid, Health Choice, or any other insurance policy?
Can the child access other eyeglass benefits at this time?
Has the child been issued and/or used a VSP, Healthy Eyes, or Donor Docs voucher within the past 365 days?
Does the child have a current (less than 12 months old) prescription for eyeglasses?
For Referring Agent Use (does not need to be put into online application):
Parent/Legal Guardian Name: ______________________________________________________________________________________
Telephone number: (_______) __________-_______________
IMPORTANT: Applications must be submitted to PBNC by a Referring Agent (not a parent or legal guardian). Referring Agents
can be a school or health department nurse, physician’s office, social worker, or school personnel. If incomplete or inaccurate
information is given, the eye care provider may decline service or require payment from the family at the time of service.